Web Site or QuickLink - Excellus BlueCross BlueShield

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Manage referrals and preauthorization requests
There are other transactions possible from the Web site, including billing resources such as electronic
remittance. (See the Billing and Remittance section of this manual for information regarding electronic
remittance and payment.)
To Register for Web Access
For Web access, providers may register directly from the Health Plan’s Web site.
Note: Facilities must complete an application that can be obtained from Provider Service
(see Contact List).
Go online to excellusbcbs.com.
Select For Providers.
Go to Register Now! and select the role that applies from the “I am a . . .” drop-down menu.
Click GO.
This will bring you to your specific registration page.
Hospital accounts department, emergency department and urgent care facilities will be directed to
complete a paper form and fax it to a specific fax number for eCommerce. The fax number is on the
form.
Participating practitioners must establish a Master Account. This account provides access to our online
tools and allows for the management of staff access.
You will be asked for your Excellus BCBS provider ID number. This is your P010 number.
Once you enter your practitioner information on the Provider Registration pages, click Submit.
eCommerce will establish the Master Account for those required to fax, and notify you when the
account is ready. Allow up to five days.
Once the Master Account is established, log on with your Username and Password and select the
Online Services menu.
Click on the Manage Staff Access link. This feature allows you to give staff members access to our
online tools. To ensure that only authorized staff have access, staff account must be managed by the
practitioner or office manager. You may create office staff accounts or delegate the task to the office
manager.
To delegate management of staff accounts, select Add Office Manager Account to create this account
prior to adding staff accounts. You will be prompted to create a temporary password. Once this account
is created, you or the office manager can add staff accounts or use the Delete Account option to
remove access for employees who leave your organization.
To Register for QuickLink
For access via QuickLink, providers should contact eCommerce (see Contact List). To use QuickLink, the
office must have a standard personal computer with communications software such as HyperTerminal. The
following specifications are included in most PCs today:

Personal computer
Communications software such as HyperTerminal
Baud: 2400 bps – 56k band
Data bits: 8
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Excellus BlueCrossBlueShield
Duplex: full
Terminal emulation: VT100 (including F5 – F12)
Parity: none
Stop: 1
Port: default
2.3.3 Electronic Billing
The Health Plan is compliant with guidelines from the Centers for Medicare & Medicaid Services (CMS)
regarding the HIPAA EDI Transaction and Code Set regulation and is prepared to receive HIPAA-compliant
transactions. Contact eCommerce for more information about electronic billing.
2.3.4 Hospital Comparison Tool
The Health Plan makes available through its Web site a hospital comparison tool. It is an online tool that
compares the performance of selected hospitals on more than 175 procedures and medical conditions. The
Health Plan offers access to the hospital comparison tool as a benefit to its members and providers.
The tool allows the user to obtain an independent comparison of hospitals within a specific geographic area
by procedure or diagnosis. Users may create a personalized report that compares hospital performance
based on information hospitals provide to CMS, state health departments or local agencies. Use of the
hospital comparison tool is completely anonymous.
The generated reports provide an analysis of patients hospitalized for certain conditions, including the
number of patients treated at each hospital (patients/year), the percentage of patients who developed
problems (complications), the percentage of patients who died (mortality), the average number of days
people stayed in each hospital (length-of-stay), and the average price the hospital charged.
2.4 Determining Member Eligibility for Benefits
Before providing services, it is important to determine financial responsibility by verifying whether the
patient has coverage for the service or should be treated as private pay. Participating providers may check
member eligibility through the Health Plan’s Web site, via QuickLink, or by calling the Health Plan.
Providers must be registered in order to have access through QuickLink or the Web. For registration
information, see the paragraphs above under Online Services.
Member ID cards also contain valuable information, but it is still important to verify benefits before providing
services.
2.4.1 Member ID Cards
Each subscriber is assigned an identification (ID) number, and each member is eligible to receive his or her
own ID card. Each of the Health Plan’s health benefit programs has its own unique ID card. See the sample
ID card at the end of this section of the manual. Sample ID cards for Child Health Plus, Family Health Plus
and Medicaid managed care are in the Government Programs section of the manual.
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What to Look for on the ID Card
Identification cards carry vital information to assist providers in doing business with the Health Plan.
Provider offices should copy the front and back of ID cards, as both sides contain important information,
including information providers need to submit claims and coordinate patient care. While our ID cards differ
from product to product, there are some standard elements:
Logo - The BlueCross BlueShield logo is on all BlueCross BlueShield plan identification cards.
Suitcase logo – Most BlueCross BlueShield ID cards include a logo that looks like an outline of a
suitcase. This logo is an indication that providers should submit claims for a member from another
BCBS health plan to the BCBS plan with which the provider participates. For example, if a provider
participates with Excellus BCBS and provides services to a member from BlueCross BlueShield of
Alabama, the claim should be submitted to Excellus BCBS.
FLRx logo – The FLRx logo indicates that the member either has prescription drug coverage through
the Health Plan’s pharmacy benefit manager (see the Pharmacy section of this manual) or is eligible for
the FLRx Value-Add Prescription Drug Discount Program.
Product Name -The name of the health benefit program (except for Child Health Plus and Family
Health Plus which instead carry a “group” identifier of “C” or “F,” respectively).
Subscriber Name – This is the name of the person holding the policy. If the patient is a dependent, the
patient’s name may not be on the ID card.
Identification Number – The identification number is that of the subscriber. It is required on all claims.
Most BlueCross BlueShield identification numbers include a three-letter prefix that must be included.
Federal Employee Program subscriber IDs have a one-letter prefix (R). ID cards for Medicaid managed
care and Family Health Plus members also include the member’s Medicaid client identification number
(CIN).
Copay Amount(s).
Telephone numbers.
Address for paper claim submittal.
2.4.2 Member Eligibility Telephone Inquiry
Before placing a call to the Health Plan, please have all required information, such as the patient’s full
name, subscriber ID and your NPI. Follow the prompts to select the correct options for your inquiry.
Knowing the patient’s type of coverage (indemnity, PPO, HMO, etc.) will help you choose the right options.
Choosing the right options can decrease the time it takes to get the information you need. Limited benefit
eligibility information is available via the Health Plan’s interactive voice response telephone system.
However, if you have selected the correct options and need to be transferred to a representative, you will
more likely be transferred to a representative trained in the appropriate product line or service area.
Because our subscriber ID numbers include an alpha character, you will be asked to speak the subscriber
ID rather than key it in via the telephone keypad. Speak slowly and clearly and say “zero” rather than “oh”
for the numeral. Do not include the three-character prefix.
Use the BlueCard eligibility telephone line or BlueExchange (online) rather than IVR to check eligibility for
out-of-area BlueCross BlueShield members. Call the appropriate FEP (federal employee program) service
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line to check eligibility for federal employees. Contact information for BlueCard and FEP is on the Contact
List.
Rochester Region providers also have access to InfoCheck. See below for instructions for using InfoCheck.
2.4.3 InfoCheck
Note: This option available to Rochester Region providers only.
InfoCheck is a telephone inquiry system that providers can use for limited eligibility and benefit information,
primarily about Blue Choice members. It is available 24 hours a day, seven days a week with two small
exceptions: from 5 a.m. to 6 a.m., Monday through Friday and from Sunday at midnight until 6 a.m.
Monday. See the Contact List for telephone numbers.
Anyone calling in will hear the following message: This line is for providers only. If you are a member, press
1. Otherwise, remain on the line.
After a brief pause to allow members to press 1, various options (described in the table on the following
page) are available to the provider.
2.5 Health Plan Publications
2.5.1 Participating Provider Manual
The Health Plan’s Participating Provider Manual is intended as a reference and source document for
physicians and other providers who participate with the Health Plan. The manual is intended to clarify
various provisions of a provider’s participation agreement.
2.5.2 Provider Newsletter
The Health Plan’s provider newsletter, Connection, is an electronic publication that is issued and posted to
the Health Plan’s Web site on a monthly basis. The newsletter is designed to keep participating providers
and their office staff apprised of developments in Health Plan policies and products.
Each month, a link to the newsletter is e-mailed to providers who have opted in to receive the publication
electronically. To opt-in, providers must go to the Health Plan’s Web site, and from the provider page, go to:
Administration > News and Updates > Get Newsletter by E-mail. The newsletter e-mail notification will only
be sent to those who have completed the opt-in process.
If the provider’s office does not have access to the Internet or does not wish to receive the newsletter
electronically, they can receive paper copies via traditional mail. To request paper copies, please contact
your Provider Relations representative.
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InfoCheck Options
Menu Option
Optical Benefits
(Requires NPI, subscriber ID
and member date of birth)
Membership & Benefits
(Requires NPI, subscriber ID
and member date of birth)
Blue Choice Referrals
(Requires NPI, subscriber ID,
member date of birth and
Excellus BCBS PIN. Option 2
requires referral No. Not a
method to generate a referral.)
Blue Choice Claims Status
(Requires NPI, subscriber ID,
member date of birth and
Excellus BCBS PIN. Info
available only for Blue Choice
claims.)
(Rochester Region providers only)
To access
option
Information available
• Date of last eye exam
• Routine eye exam benefit
Press 1
• Date of last eyewear purchase
• Routine eyewear benefit
• Cataract surgery eyewear benefit
Non Blue Choice contracts
• Contract type
• Suffix number
Blue Choice contracts
• Contract type
• Name, suffix and effective date of individual on
Press 2
contract
• PCP / Alt PCP name and office visit copay
• Specialist office visit copay
• Mental health office visit limits and copay
• Chiropractor office visit copay
Press 3
Press 4
Transfer to Blue Choice
Press 5
Transfer to Blue Shield
Press 6
End call
Press 9
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Verify existing referral information only. Cannot
generate referral via InfoCheck.
•
•
Claim number, procedure code, diagnosis code
Date paid or denied and, if paid, the amount by
procedure code
During business hours, this transfers the caller to a
Blue Choice representative.
During business hours, this transfers the caller to a
Blue Shield representative.
Ends the call.
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2.5.3 Ad Hoc Communications
As needed, the Health Plan sends written notifications to participating providers regarding new and revised
policies and procedures and other information of value. The Health Plan issues bulletins, letters and other
notices in instances when notification is required outside the normal newsletter schedule, or when the
information affects only a small, specific audience of providers.
2.6 Provider Office Environment
2.6.1 Office Site Review
The Health Plan may conduct site reviews of the office locations of physicians and other health care
providers at initial credentialing and when a provider opens a new location.
An office site review includes assessments of patient safety and privacy, office operations and
confidentiality, appointment and accessibility, security of pharmaceuticals and prescription pads, and office
record maintenance. The Credentialing Site Visit Checklist (included at the end of this section and on the
Web site) lists the criteria Health Plan reviewers use during a site review.
The Health Plan will conduct a site visit upon receiving two formal or informal complaints within 12 months.
A complaint may be but is not limited to physical appearance, handicap access, waiting room or exam room
space. Elements from the Credentialing Site Visit Checklist will be utilized for the visit. The areas to be
reviewed include but are not limited to the following requirements on the checklist: Facility and
Environment, Office Operations, Pharmaceuticals and Office Record Maintenance. All applicable standards
must be met.
Wheelchair Accessibility
As part of the Office Site Review, Health Plan reviewers gather information to better serve members with
disabilities. This information does not affect a provider’s credentialing status. Accessibility information is
included in Health Plan provider directories.
2.6.2 HIPAA Compliance
Note: This section gives a general overview of HIPAA requirements. For information
about Health Plan compliance with HIPAA standards on privacy and confidentiality, see the
Introduction section of this manual. For information regarding HIPAA-compliant availability
of eligibility, claims, and referral information, see paragraphs about Member Eligibility
Remote Access Inquiry, Online Inquiry Systems, as well as referral and preauthorization
information in the Benefits Management section of this manual. For information about
Health Plan compliance with HIPAA standards on electronic submission of claims, see the
Billing and Remittance section of this manual.
The Health Insurance Portability and Accountability Act of 1996, Public Law 104-191, (commonly known as
HIPAA), was designed to improve the efficiency and effectiveness of the health care system. It includes
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administration simplification provisions that require the U.S. Department of Health and Human Services to
adopt national standards for electronic health care transactions. Recognizing that advances in electronic
technology could erode the privacy of health information, Congress incorporated into HIPAA, provisions
that mandate the adoption of federal privacy protections for individually identifiable health information. This
information is referred to as Protected Health Information, or PHI.
The HIPAA Privacy Rule provides standards for the protection of PHI in today’s world where information is
broadly held and transmitted electronically. HIPAA’s privacy rule requires that health care providers and
other specified entities (“covered entities”) take certain actions to maintain confidentiality. Some of these
actions are:
Notifying patients about their privacy rights and how their PHI can be used
Adopting and implementing privacy procedures
Training employees to understand privacy procedures
Designating a Privacy Officer responsible for seeing that privacy procedures are adopted and followed
Securing patient records containing PHI so they are accessible only to specified individuals
Who Must Comply
The following individuals and organizations must comply with the HIPAA standards. They are referred to as
“covered entities.”
Health care providers who electronically conduct the financial and administrative transactions listed
under Applicable Transactions, below
Health plans such as this Health Plan and Medicare and Medicaid, employer plans under the Employee
Retirement Income Security Act (ERISA), Indian Health plans, and self-administered plans (except
those with fewer than 50 participants)
Health care clearinghouses
Business associates of any of the covered entities, if the business associate has contracted to comply
with HIPAA
These covered entities are required to comply even if a third party conducts the specified transactions on
their behalf.
Applicable Transactions
All covered entities that conduct any of the following standard transactions are required to use HIPAAcompliant electronic language and codes:
Health care claims or equivalent encounter information
Health care payment and remittance advice
Coordination of benefits
Health care claim status
Enrollment and disenrollment in a health plan
Eligibility for a health plan
Health plan premium payments
Referral certification and authorization
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Compliance Dates
Covered entities had until April 14, 2003, to comply with the act’s privacy regulations. Covered entities were
to have complied with HIPAA standards for electronic claim submission (ANSI 837) by October 16, 2003,
subject to fine, although a one-year delay was granted to “small” organizations.
2.6.3 Updating Practice Information
The Health Plan requires that providers submit updated information whenever there are any changes
to a provider or his/her practice. This is necessary to keep directory and claims systems information
current. This includes changes in:
Provider Name
Provider Tax ID
Provider NPI
Provider Taxonomy Codes
Payment Address
Directory Listing: that is, provider address, phone number, fax number and, for primary care providers
who participate in managed care products, whether the practice is accepting new patients
Service Addresses
Changes in coverage arrangements
When one or more practitioners join the group practice
When one or more practitioners leave the group practice
To notify the Health Plan of such changes, complete a Provider Information Update Form, indicating what
information has changed. A sample form is provided at the end of this section. The form is also available
from the Provider page on the Health Plan’s Web site. Select Administration from the menu bar at the top,
then click on Update Practice Information Update in the menu on the left. At this point, chose either the
online or paper form.
The online form requires the provider to log on. The completed paper Provider Information Update Form
may be faxed or mailed to Provider File Maintenance. Address and fax number are included on the form.
Note: Providers also may notify the Health Plan of changes in practice information by
submitting a letter, on office letterhead, specifying what the changes are. Letters also
should be faxed or mailed to Provider File Maintenance.
If a practitioner who is not already participating is joining a currently participating group practice, the Health
Plan also requires that provider to complete an Initial Practitioner Information Form, also available via the
Health Plan’s Web site. To get to the form from the provider page of the Web site, go to: Administration >
Print Forms and Templates > Credentialing. A sample form is provided at the end of this section.
2.6.4 Closing/Opening a Practice
In signing a participation agreement with the Health Plan, a participating physician agrees to accept as
patients those members who elect to receive care from the physician, or those whom the Health Plan
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assigns to the physician. If the physician’s practice is at capacity, the physician may close his/her practice
to new managed care patients.
However, a participating physician shall not close or reopen his/her practice to new patients without giving
the Health Plan 90 days prior written notice. In all cases, a participating physician shall continue to permit a
current patient who has other health coverage to designate the physician as his/her PCP in the event the
patient chooses to enroll as a member of the Health Plan.
2.6.5 Access to Care
The Health Plan has established appointment availability standards to provide reasonable patient access to
care. In addition, physicians who participate in the Health Plan’s managed care programs are required to
advise the Health Plan in writing of covering participating physician arrangements or changes to those
arrangements, including situations in which physicians in the same office are covering for each other.
See the Quality Improvement section of this manual for additional information about the Health Plan’s
requirements for accessibility, including access to after hours care.
2.6.6 Member Payments
Except in limited circumstances (see paragraphs headed Charging for Copying of Medical Records, and
Patient Financial Responsibility Agreement), Health Plan participating providers cannot charge and/or
collect a deposit from or seek any form of reimbursement from a Health Plan member, or persons acting on
the member’s behalf, other than the permitted copayments, coinsurances, or deductibles associated with
covered services.
Note: Cost-sharing information (copayments, coinsurance and deductibles) for specific
member contracts is available via the QuickLink and the Web site inquiry methods.
Providers may also call Provider Service for this information.
Charges Not Permitted
Participating providers cannot:
Bill a managed care member for services, unless the member has selected the provider as his/her PCP
or the member has a valid referral from his/her PCP to see the provider. To charge a member in limited
circumstances (non-covered services), the member must have signed a valid Patient Financial
Responsibility Agreement (see below) or other waiver.
Charge a member when the member is covered by two health plans. For example, if the Health Plan is
primary and a balance remains after the Health Plan has reimbursed its allowed amount for covered
services, providers must bill the secondary carrier.
Charge a member for administrative fees, such as completing claims forms or triplicate prescriptions
that are standard overhead costs. Providers may bill a member if the member fails to show up for an
appointment, but only if this policy is prominently displayed in the office and communicated to the
physician’s patients. The Health Plan does not pay for missed appointments.
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2.6.7 Patient Financial Responsibility Agreement
The Health Plan encourages participating providers to ascertain, prior to supplying services to a Health
Plan member, whether those services are covered under the member’s health benefit program. (See
previous paragraphs for information about determining member eligibility.) This is important because, as
stated above, participating providers may not charge or collect a deposit from or seek any form of
reimbursement from a Health Plan member, or a person acting on the member’s behalf, other than the
permitted copayments, coinsurances, or deductibles associated with covered services. Providers must
notify the member in writing prior to providing a service that is not covered informing the member that
he/she will be liable for payment.
In situations where a member does not have a valid referral, or the member’s eligibility for requested
outpatient services cannot be determined because the Health Plan’s member eligibility systems are not
available, participating providers may elect to have the member complete and sign a Patient Financial
Responsibility Agreement. (A sample form is available on the Health Plan Web site or from Provider
Service.)
Having the member sign the form may allow the provider to bill the member for services that the Health
Plan did not cover because:
The managed care member self-referred for the service, or
The services were not a covered benefit under the member’s benefit package, or
The services were not within the scope of the provider’s participation agreement, or
The member had not completed the required waiting period for treatment of a pre-existing condition.
Once a member has signed a Patient Financial Responsibility Agreement, the provider should keep the
form on file.
2.7 Medical Records
The Health Plan requires that participating provider medical records be kept in a manner that is current,
detailed, organized, that complies with all state and federal laws and regulations, and that is accessible by
the treating provider and the Health Plan. To support this requirement, the Health Plan has established
Medical Record Documentation Standards. Information regarding these standards is included in the Quality
Improvement section of this manual.
2.7.1 Access to Medical Records
By the Health Plan
A participating physician or other provider must maintain medical records and provide such medical,
financial and administrative information to the Health Plan as it may reasonably require to ensure
compliance with applicable laws, rules, and regulations; and for program management purposes.
Participating physician offices must:
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Maintain medical records in a manner that is individualized, current, organized, detailed, and
confidential.
Make records available to Health Plan staff for review when requested.
Provide copies of patient charts to the Health Plan without cost, per the provider’s participation
agreement.
Note: Medical record documentation auditing and reporting are part of “health care
operations” as defined by HIPAA and thus do not require patient authorization for release
of protected health information. For information about HIPAA, see the paragraph headed
HIPAA Compliance that appears earlier in this section of the manual.
By Members
Members have the right to see their medical records. The Health Plan member handbooks state that any
requests for medical records should be directed, in writing, to a member’s physician. Each member age 18
or over, or an emancipated minor, must sign his or her own written request.
2.7.2 Charges for Photocopying Medical Records
Subject to the terms of a provider’s participation agreement, a participating provider may not charge the
Health Plan or the Department of Health for photocopying a patient’s medical record. New York State
Public Health Law Article 1, Title 2, Section 18 (2.e) states that providers may impose reasonable charges
when a patient (subject) requests copies of his/her medical records, not to exceed 75 cents per page.
However, members may not be denied access to their records due to inability to pay.
2.7.3 Advance Care Directives
The Health Plan encourages providers to discuss with members end-of-life care and the appointment of an
agent to assume the responsibility of making health care decisions when the member is unable to do so.
Information for members about advance care planning is available on the Health Plan’s Web site.
The Health Plan’s Medical Records Documentation Standards state that medical charts must include
documentation indicating that adults age 18 years and older, emancipated minors, and minors with children
have been given information regarding advance directives. See the Quality Improvement section of this
manual for additional information about this requirement and about advance care directives.
Note: Treatment decisions cannot be conditional on the execution of advance directives.
2.8 BlueCard® Program
The BlueCross BlueShield Association sponsors the BlueCard Program, a program that helps make it
possible for members covered by affiliated BlueCross BlueShield plans to maintain the protection of
BlueCross BlueShield coverage even when they are away from the area served by their home plan.
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Most BlueCross BlueShield members have a three-letter alpha prefix at the beginning of the member
identification number. This prefix is critical to identifying the member’s home plan and must be included on
all claims. In addition, a suitcase logo located on member’s identification card indicates that the claim for
the out-of-area member should be submitted to the plan with which the provider participates (i.e., Excellus
BCBS).
2.8.1 BlueCard Terms

A Home Plan is the plan in which the patient is enrolled.
A Host Plan (local plan) is the plan in the area where the services are rendered.
Prefix is the three-letter alpha prefix in front of the member identification number. The prefix is critical
to identifying the member’s home plan and expediting claim processing.
2.8.2 Contacting the Home Plan
Providers should contact the Home Plan for the following:
Membership
Benefits
Member cost-sharing amounts
Referrals and authorizations
There are two ways to contact the Home Plan.

BlueExchange. BlueExchange is the BlueCross BlueShield interplan system for select HIPAA
transaction processing, including checking eligibility, checking claim status and requesting referrals.
BlueExchange uses standard formats, secure and reliable plan-to-plan communications, common
validation processes, and performance measurements. Providers can access BlueExchange via the
Health Plan’s Web site or QuickLink. (See the paragraphs regarding online inquiry systems.)
BlueCard 800# network. Providers may call the BlueCard toll-free telephone number (see Contact
List) to be routed to the member’s Home Plan, after providing the alpha prefix.
2.8.3 BlueCard Rules

A provider who participates with a local BlueCross BlueShield plan for indemnity, PPO, EPO, POS and
Medicare Advantage products is also a participating provider for out-of-area BlueCross BlueShield
members with these products. (See the Introduction section of this manual for definitions/descriptions
of these types of products.)
For HMO plans, an out-of-area authorization must be obtained from the member’s plan in order for
services to be covered (except for emergency services). There may be some exceptions to this policy,
based on the member’s contract.
Workers’ Compensation and No Fault claims cannot go through BlueCard. For these claims, the
provider must submit directly to the patient’s Home Plan.
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Providers may submit all other claims to their local BlueCross BlueShield plan just as they would claims
for locally enrolled subscribers.
Providers must bill all BlueCross BlueShield claims, including BlueCard claims, with the three-letter
alpha prefix. The letters in the prefix indicate the patient’s Home Plan.
2.8.4 Contact Local Plan for BlueCard Claim Inquiries
There are three options for claim inquiries.
Use BlueExchange via the Health Plan’s Web site or QuickLink.
Use the paper adjustment form provided by the Health Plan. (See the Billing and Remittance section of
this manual.)
Call the Health Plan’s Provider Service unit (see Contact List).
2.9 Samples, Forms and Charts
These samples, forms and charts are reproduced on the following pages:
Chart: Contents of the Health Plan Web Site
Sample: Member ID Card
Chart: Credentialing Site Visit Checklist
Form: Provider Information Update Form (3 pages)
Form: Initial Practitioner Information Form (3 pages)
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Contents of the Excellus BlueCross BlueShield Web Site
excellusbcbs.com
For Providers
For Members
Online Services: Member Eligibility, Benefits, Claims, Referrals, Admissions, Preauthorizations, Access
a Patient’s Health Record, Compare Hospital Quality, Manage Staff Access
Patient Care: Health Promotion & Prevention, Managing Illness, Behavioral Health, Quality &
Performance, Medical Policies, Clinical Practice Guidelines, Clinical Tools, Health Care Planning
Administration: Fee Schedules, Billing Resources, Physician Advisory Committee, Print Forms and
Templates, Provider Directories, Update Practice Information, Credentialing, Provider Manuals,
Glossary, News and Updates
Prescription Drugs: Check Our Drug List, Drug Management Programs, Prescribing Support, Help
Patients Save Money, Patient Educational, Find a Pharmacy, Prior Authorization Forms
Contact Us: Contact Us, About Us, News Room, Health Policy & Research, Compliance Notices
My Account: Change Your Doctor, Change Your Address/Phone, Request ID Card, Print Forms,
Manage Your Policy, Enroll in a New Policy, Share Your Protected Health Information, View
Electronic Documents, Flexible Spending Account, News and Updates
Health & Wellness: Healthy Rewards, Manage Your Health, Healthy Living, Help With Illness, Quality &
Safety, Planning for Future Needs, Editorial Policy
Health Plans: Blue On Demand, Health Plans, Medicare Plans, Dental Plans, Seeking Care, BlueCard®
Program, BlueCard Worldwide®, Frequently Asked Questions
Prescription Drugs: Check Our Drug Lists, Save Money on Your Prescriptions, Find a Pharmacy,
Manage Your Medications, View Your Drug Claims, Medicare Drug Plan Information, Educational
Materials
Find a Doctor or Hospital: Find a Doctor, Find a Dentist, Find a Hospital, Compare Hospital Quality,
Find a Pharmacy, Find a Cancer Treatment Center, Find an After Hours/Urgent Care Center, Find
Other Providers
For
Employers
Information for employers that offer Health Plan products to employees. Includes the following: Policy
Manager, Health & Wellness, Health Plans, Prescription Drugs, Employer Resources
For Guests
Information for guests (individuals who may be looking for coverage) includes the following: Health Plans,
Health & Wellness, Prescription Drugs, Find a Doctor or Hospital
For Brokers
Information for brokers who sell Health Plan products.
List subject to change.
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Sample Member ID Card
Information may vary in appearance or location on the card, but all cards display basically the same
information (such as product name, member name and ID number, customer service telephone number,
claims address, etc.). Other information on the card, such as prior authorization requirements or other
telephone numbers, may be specific to the Health Plan product under which the member has coverage.
HealthyBlue Sample ID Card
Copay and Deductible Option
HealthyBlue
Member Name
You are enrolled in a PPO Product. Dependents
are not listed on PPO ID cards.
No referrals are required.
Member ID
BIN
Effective Date
Plan Code
610475
00/00/00
302/802
Plan
PCP Copay
Children up to age 19
Specialist Copay
Emergency
Deductible
PPO
$XX
$0
$XX
$XXX
$XXX/$XXXX
Rx
Front of HeathyBlue Member ID Card
www.excellusbcbs.com
Customer Service:
Prior Authorization Requirements
Certain services require prior authorization.
Please visit our Web site or call the number at
the right to confirm if a service requires prior
authorization.
Hospital or physicians: file claims with local
BlueCross and/or BlueShield Plan.
Pharmacy Benefit:
Prior Authorization:
1-800-499-1275
1-800-724-5033
1-800-363-4658
Excellus BlueCross BlueShield
PO Box 22999
Rochester, NY 14692
A nonprofit independent licensee of the BlueCross BlueShield
Association
Pharmacy benefits administrator
Back of HealthyBlue Member ID Card
June 2009
2—23
2.0 Administrative Information
Excellus BlueCrossBlueShield
Credentialing Site Visit Checklist
The Health Plan may perform an office site review as part of the provider credentialing/recredentialing
process for PCPs, OB/GYNs and behavioral health providers. Provider sites must meet the following
standards or have a corrective action plan in place for the credentialing process to proceed.
Facility and Environment
ο Clean, private restroom for patients*
ο Waiting and treatment rooms clean, sanitary and of adequate size*
ο Patient care areas ensure privacy*
ο Handicap accessible*
Office Operations
ο Confidentiality policy for staff*
ο Process to identify and contact patients who miss appointments
Access to Care
ο Emergency coverage, 24 hours a day, seven days a week
ο Urgent medical care available within 24 hours
ο Adult base-line medical exam available within 12 weeks
ο Routine health maintenance care within four weeks
ο Non-urgent sick visits within 48 to 72 hours
ο Well-child visits within four weeks
ο Routine behavioral health care within 10 business days
ο Urgent behavioral health care within 48 hours
Pharmaceuticals
ο Medications and supplies stored in secure location*
ο Prescription pads stored in secure location*
Office Record Maintenance
ο System in place to ensure a neat and legible record for each patient
ο Patient name, ID number on each page, all entries dated, sequential and signed or initialed by author
ο Problem list included
ο Office records stored securely to maintain confidentiality and privacy*
ο Records kept for individual patients
ο Records maintained for period required by law
ο System in place to ensure that provider reviews all clinical information
ο Allergies displayed prominently
ο System to capture biographic and personal data and appropriate medical history
* Asterisked items are reviewed upon complaint.
2—24
Rev. 7/08
June 2009
Provider Information Update Form
A nonprofit independent licensee of the BlueCross BlueShield Association
Instructions: Please complete this form and return by mail or fax to the addresses shown on the last page. This form must be
personally signed by the provider (no signature stamps can be accepted).
1) Provider Name: __________________________________________________
2) Provider's Tax ID Number: _________________________________________
individual number
group number
If this is a group number, what is the name of the group? ________________________________________________________________________
3) Provider's License Number: __________________________________________ State Issued ______________________
4) NPI (National Provider Identifier) Number(s) for:
Individual Provider NPI (Type 1): ___________________________________________________________________
Group – Entity NPI (Type 2): ________________________ Group Name: _________________________________
Group – Entity NPI (Type 2): ________________________ Group Name: _________________________________
5) Taxonomy Code for:
Primary Specialty:
_______________________________ Taxonomy Code: ______________________________
Second Specialty:
_______________________________
Third Specialty:
_______________________________ Taxonomy Code: ______________________________
Taxonomy Code: ______________________________
***For the remaining questions, fill out only the ones that require a change or update to your information ***
6) Address Change: (please check appropriate box)
Street Address _____________________________________________________________
Suite/Bldg # _______________________________________________________________
Address/telephone change
City _____________________________________________________________________
Additional location/telephone
State ____________ ZIP Code _________________ County ________________________
Terminating location/telephone
Phone ( )____________________________ Fax ( )_____________________________
Termination date of location/telephone __________________________
Billing Address/Telephone change
Effective date of new address _________________________________________________
Email: Office _____________________
Handicap accessible? Yes
No
Accessible to public transportation? Yes
Old Address: (if address change checked)
Physician _____________________________
No
Street Address _____________________________________________________________
Suite/Bldg # _______________________________________________________________
City _____________________________________________________________________
State ____________ ZIP Code _________________ County ________________________
Phone ( )____________________________ Fax ( )_____________________________
Email: Office _____________________
Physician _____________________________
7/08
7) Is the tax ID listed above a change? Yes
No
Effective date of new tax ID # _____________________
8) What hours are you available to see patients?
What is the Old tax ID # __________________________
(For more than 2 locations, please attach an additional sheet – Paper only)
Location 1: _____________________________
Office Start
(If yes, attach a copy of W-9 Form – Paper only)
Location 2: _____________________________
Office End
Office Start
Monday
Monday
Tuesday
Tuesday
Wednesday
Wednesday
Thursday
Thursday
Friday
Friday
Saturday
Saturday
Sunday
Sunday
9) Are you accepting new patients?
Yes
Office End
No
10) For Primary Care Physicians Only – List names of on-call physicians below (attach additional sheet if necessary – Paper only)
Name
Effective Date
Cross Cover?
Yes No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
11) What languages are spoken by practitioners and clinical personnel in this office?
_________________________________________________________________
12) Hospital affiliations:
Hospital Name
Hospital Address
7/08
13) Do you have a nurse practitioner or physician's assistant who works with you?
Name
Yes
No
NP or PA
NP PA
NP
PA
NP
PA
NP
PA
If yes, please list below.
Effective Date
14) Additional comments:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Practitioner's signature required
_________________________________________________________________
Date __________________
(stamps not acceptable)
Please mail or fax this completed form to the address below that is
located closest to your primary office:
For Rochester area:
Excellus BlueCross BlueShield
Provider File Maintenance
165 Court Street
Rochester, NY 14647
Fax Number: (585) 262-2017
For CNY, Southern Tier & PA areas:
Excellus BlueCross BlueShield
Provider File Maintenance
333 Butternut Drive
Syracuse, NY 13214
Fax Number: (800) 676-6285
For Utica/Watertown & VT areas:
Excellus BlueCross BlueShield
Provider File Maintenance
12 Rhoads Drive
Utica, NY 13502
Fax Number: (800) 676-6285
7/08
Initial Practitioner Information Form
A nonprofit independent licensee of the
BlueCross BlueShield Association.
To begin your enrollment process, please use this simple, standardized form. Please complete all information as
it applies to your specialty. Information that does not apply to your specialty may be left blank.
DATE:
Last Name:
First Name:
Date of Birth:
Gender:
Primary Telephone No.: (
)
-
Middle Initial:
Male
Female
Primary Fax No.: (
Primary Office Street Address:
)
Suite #:
Primary Office City:
State:
County:
Zip:
-
E-mail Address:
Social Security No.:
DEA Certificate No.:
State License No.:
Licensed State:
UPIN (if applicable):
Tax ID:
Group Tax ID:
Provider Type (MD, DO, DC, DDS, DMD, DPM, etc) :
Primary Specialty:
Taxonomy Code:
Second Specialty:
Taxonomy Code:
Third Specialty:
Taxonomy Code:
Applying As:
PCP
Are you board certified?
Specialist
Yes
Are you registered with CAQH?
Allied/Consulting Health Professional
No
Yes
If Yes, board name:
No
NPI number:
If Yes, CAQH Provider ID:
Group NPI Number:
Other NPI Number:
Name of Group or Employer (if applicable):
Group Number:
Effective date of group affiliation:
6/09
Is Main Office Address Handicap-accessible?
Yes
No
Second Office Address (if applicable):
Street Address:
City:
County:
State:
ZIP Code:
Office Phone: (
)
-
ext.
Is Second Office Address Handicap-accessible?
-
Office Fax: (
)
-
Yes
No
Billing Address:
Street Address:
City:
County:
State:
ZIP Code:
Phone: (
)
-
ext.
Fax: (
-
)
-
Medicare No.:
Workers’
Compensation No.:
Medicaid No.:
CLIA Cert No.:
What languages other than English do you speak?
Hospital affiliations:
Hospital Name
Office Contact Person Name:
Hospital Address
Phone: (
)
-
ext.
Note: If you have already completed your application with CAQH, please ensure that you have authorized all applicable
organizations to access your data. Using the CAQH Universal Credentialing DataSource does not grant participation or
constitute applying for participation with any of the above organizations. If applicable, please contact the health plan
directly to request contracting information.
Signature of person completing form: _____________________________________________________
Title:
Date:
PLEASE ATTACH W-9 FORM, COPY OF LICENSE, AND A COPY OF AGREEMENT
SIGNATURE PAGE WITH THIS INFORMATION. ENROLLMENT WILL NOT BE
PROCESSED WITHOUT THIS DOCUMENTATION.
6/09
Please return this form by mail or fax to the applicable Network Management office:
Rochester: Excellus BCBS Rochester Region, Attn: Network Management
Address: 165 Court Street, Rochester, NY 14647
Fax:
585-399-6664
Utica: Excellus BCBS Utica Region, Attn: Provider Relations
Address: 12 Rhoads Drive, Utica, NY 13502
Phone: Contact your assigned Provider Relations representative
Fax:
315-731-2530
Syracuse: Excellus BCBS CNY Region, Attn: Network Management
Address: 333 Butternut Drive, Syracuse, NY 13214
Fax:
315-671-6799
Southern Tier: Excellus BCBS Southern Tier
Elmira Office:
Address: 150 North Main Street Suite 1, Elmira, NY 14901
Phone: 607-734-8196
Fax:
Not Available
Binghamton Office:
Address: 53 Chenango Street, Binghamton, NY 13901
Phone: 607-723-6821
Fax:
Not Available
6/09

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